Failure to Palpate and Failure to Image: Quantifying Standard-of-Care Departure in Fatal Delayed Intracranial Foreign Body Diagnosis, Indonesia

Abstract

Background. Retained intracranial foreign bodies in patients alert at a Glasgow Coma Scale (GCS) of 15 are a rare, lethal and medicolegally exposed failure in Indonesian assault casework, yet the share attributable to specific documentable procedural omissions is unquantified.

Objective. To quantify the association of failure to palpate the wound bed and non-adherence to computed tomography (CT) guidelines with delayed diagnosis, and to derive medicolegal attribution metrics.

Methods. This retrospective multi-centre cohort (STROBE) examined 45 confirmed retained intracranial foreign bodies among 1,240 mild traumatic brain injury presentations (prevalence 3.63%, 95% CI 2.72–4.82) at three North Sumatran trauma centres, 2019–2023. Diagnosis beyond 24 hours was the pre-specified outcome. Analysis of aggregate data used exact conditional and Firth-penalised odds ratios, Holm multiplicity control, and partial identification of the multivariable model across 4,000 admissible joint arrangements.

Results. Diagnosis was delayed in 14 of 45 cases (31.1%, 95% CI 19.5–45.7). Failure to palpate the wound bed carried an exact conditional odds ratio of 29.86 (4.79–281.0; p < 0.001) and CT non-adherence 20.88 (3.57–174.7; p < 0.001). Palpation failure achieved sensitivity 78.6%, specificity 90.3% and area under the curve 0.844; the attributable fraction was 76.3% (50.8–96.1). Adjusted odds ratios were bounded, not estimated, because aggregate data cannot identify a multivariable model.

Conclusion. Two zero-cost omissions dominate a fatal diagnostic failure; recording wound-bed palpation and the imaging decision is clinically protective and, under KUHAP Articles 133 and 179 and Law No. 17 of 2023, is what a visum et repertum requires.